345920017-4-17-2025-59-AS-KHOS-DFZKWN-20250423081612

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345920017
Report Date: 04/17/2025
Date Signed: 04/17/2025 03:01:38 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/03/2024 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 59-AS-20241203090402

FACILITY NAME:	ILLINOIS HOME, LLC		FACILITY NUMBER:	345920017
ADMINISTRATOR:	SAMSON, DEXTER C.		FACILITY TYPE:	737
ADDRESS:	5035 ILLINOIS AVE		TELEPHONE:	(916) 206-9433
CITY:	FAIR OAKS	STATE: CA	ZIP CODE:	95628
CAPACITY:	4	CENSUS: 4	DATE:	04/17/2025
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Dexter Samson, Administrator		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff are barricading residents while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Hood arrived at the faciltiy and met with Administrators, Dexter Samson and Jasmin Samson, to deliver findings regarding the complaint allegation listed above.

During the investigation, LPA conducted interviews, toured the facility, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows:

Allegation: Staff are barricading residents while in care.

Relevant party reported that, on November 26, 2024, they witnessed staff barricading residents (R1 & R2) in the common area of the facility by using two (2) overturned couches to obstruct their passageway.

** Report continued on 9099-C **

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20241203090402

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ILLINOIS HOME, LLC	FACILITY NUMBER: 345920017
	VISIT DATE: 04/17/2025

NARRATIVE

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Interview with Administrators indicated that R1 and R2 were not barricaded in the living room and there was plenty of space for the residents to leave the living room if they wanted to. Administrators stated that the couches were in an L-shape and were upright. Administrators denied that the couches were overturned. Interviews conducted with staff members S1, S2, S3, and S4 indicated that they did not witness staff barricading R1 and R2 in the common area on November 26, 2024. S1 stated that the couches were in an L-shape but not a closed L-shape. S2 stated that there was plenty of space between the couches and the couches were not upside down. S3 stated that there was plenty of room for the clients to get around the couches in the living room and the couches were not upside down. S4 stated that there was plenty of room to get in and out of the living room and the couches were still in a square shape. Interviews with S1, S2, S3, and S4 indicated that they have never witnessed staff barricading residents or obstructing their passageways at the facility. LPA obtained written statements from staff members S2, S3, S4, S5, and S6 regarding incident reported in complaint. All statements denied that staff barricaded R1 and R2 in the living room on Novemeber 26, 2024.

During visits conducted on December 4, 2024, December 19, 2024, March 4, 2025, March 14, 2025, and April 17, 2025, LPA did not observe residents being barricaded or their passageways being obstructed at the care home.

Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview was conducted. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 04/17/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

LIC9099 (FAS) - (06/04)

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